Should 9 Year Olds Be Screened for High Cholesterol?

In addition to checking growth and health, administering immunizations and prescribing medications, pediatricians have something else on their to-do list: checking cholesterol levels in all children.

In November, a report from the National Heart, Lung and Blood Institute (NHLBI), endorsed by the American Acedemy of Pediatrics (AAP), put out new recommendations for cholesterol screening and treatment in children.  These recommendations replace the 2008 recommendations from the AAP that recommend screening high-risk children, including those with a family history of early heart disease or high cholesterol and certain conditions such as obesity, high blood pressure or diabetes.

While much of the previous recommendations still stands, the revised recommendations include universal screening for all children between the ages of 9 to 11. The reason that this age range has been chosen is that cholesterol drops during puberty but then increases again as adolescents approach adulthood.

Why the change?
According to the NHLBI report, atherosclerotic cardiovascular disease (CVD), in which the artery walls thicken as a result of the accumulation of fatty materials such as cholesterol, is the leading cause of death in North Americans. While the true form of “atherosclerosis” is rare in childhood and adolescence, the risk factors and risk behaviors in childhood can accelerate the development of it.

Here are key points from the NHLBI report on why universal testing is needed:

-Approximately 30-60% of children with high cholesterol are missed with the current testing protocol, as many do not have reliable or accurate family histories to guide them.

-Studies show that children with abnormal lipid levels such as high cholesterol are at increased risk for CVD as adults

-Better identification and control of abnormal lipids in childhood should reduce CVD risk beginning in early adulthood. Of particular importance are those with heterozygous hypercholesterolemia (FH), a genetic condition of high cholesterol levels typically requiring medication to keep cholesterol levels down.

-When the original guidelines were made, the focus was on identifying children with high LDL (bad cholesterol). But now a new combined pattern of abnormal lipids associated with obesity includes normal to mild elevation of LDL, high Triglycerides (type of fat in blood stream) and low HDL (good cholesterol). This new pattern has also been shown to increase CVD risk in adulthood.

Reactions
There have been some not-so-favorable reactions to these new recommendations. In this news article, Dr. Chad Teeters, a cardiologist at the University of Rochester Medical Center, points out that testing will be expensive and provide little benefit unless children get on cholesterol lowering medication — with no evidence that such drugs will help long term.

Yoni Freedhof, MD who blogs at Weighty Matters doesn’t agree with universal testing either:

In medical school I was taught that over 90% of diagnoses can be made on the basis of history alone. Rather than recommending a blood test, how about recommending physicians take lifestyle histories and that way, instead of just focusing on those kids who are unfortunate and predisposed enough to be developing “adult” style chronic diseases at a frighteningly young age, we can focus on all kids, including those whose youth might still be protecting them against an awful lifestyle. Don’t those kids need help too?

I agree with Freedhof that prevention for all is key — and that it’s not beneficial to only counsel children (and their parents) with high cholesterol. Additionally, research shows that half of children with high cholesterol will have it as adults. So that means the other half won’t. So does it help (or hurt) to alarm those children who will grow out of their high cholesterol?

On the other hand, a high cholesterol may be the wake-up call some parents need to get on a healthier path and a select few will be glad to discover their child has a genetic condition (like FH) so they can act early.

What do you think of all of this? Do you want your child being screened for high cholesterol as early as age 9?

For those who want more details, see the testing recommendations below or go to the full report.

Review of the recommendations

What the numbers mean for children
Total cholesterol: Acceptable <170mg/DL, borderline 170-199, high >200
LDL: Acceptable <110, borderline 110-129, high >130
HDL: Acceptable >45, borderline 40-45, low <40
Triglycerides 0-9 years: Acceptable 75, borderline 75-99, high >100
Triglycerides 9-16 years: Acceptable 90, borderline 90-129, high >130

Birth to 2 years: no screening
2-8 years: no routine screening unless the child has:
-a parent, grandparent, aunt/uncle, or sibling with heart attack, chest pain, stroke, any cardiac surgery <55 years in males and <65 years in females.
-a parent with Total cholesterol ≥240 mg/dL
-diabetes, hypertension, BMI ≥95th percentile or smokes cigarettes
9-11 years: universal screening
12-16 years: no routine screening unless the child has:
– a parent, grandparent, aunt/uncle or sibling with heart attack, chest pain, stroke, cardiac surgery, sudden death at < 55 years in males, < 65 years in females
-a parent with TC ≥240 mg/dL
-other high risk conditions
17-21 years: Universal Screening